Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review.

The incidence of cervical cancer in low- and middle-income countries (LMICs) is five times higher than that observed in high-income countries (HICs). This discrepancy is largely attributed to the implementation of cytology-based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self- and provider-collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model-based cost-effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost-effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology-based screening was shown to be the least effective and most costly screening method. Whether provider-collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow-up and VIA test performance. Self-collected HPV testing was cost-effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost-effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self-collection of samples if it yields gains in population coverage.

Self-collection based HPV testing for cervical cancer screening among women living with HIV in Uganda: a descriptive analysis of knowledge, intentions to screen and factors associated with HPV positivity.

BACKGROUND: Women living with HIV (WHIV) are disproportionately impacted by cervical dysplasia and cancer. The burden is greatest in low-income countries where limited or no access to screening exists. The goal of this study was to describe knowledge and intentions of WHIV towards HPV self-collection for cervical cancer screening, and to report on factors related to HPV positivity among women who participated in testing. METHODS: A validated survey was administered to 87 HIV positive women attending the Kisenyi Health Unit aged 30-69 years old, and data was abstracted from chart review. At a later date, self-collection based HPV testing was offered to all women. Specimens were tested for high risk HPV genotypes, and women were contacted with results and referred for care. Descriptive statistics, Chi Square and Fischer-exact statistical tests were performed. RESULTS: The vast majority of WHIV (98.9%) women did not think it necessary to be screened for cervical cancer and the majority of women had never heard of HPV (96.4%). However, almost all WHIV found self-collection for cervical cancer screening to be acceptable. Of the 87 WHIV offered self-collection, 40 women agreed to provide a sample at the HIV clinic. Among women tested, 45% were oncogenic HPV positive, where HPV 16 or 18 positivity was 15% overall. CONCLUSIONS: In this group of WHIV engaged in HIV care, there was a high prevalence of oncogenic HPV, a large proportion of which were HPV genotypes 16 or 18, in addition to low knowledge of HPV and cervical cancer screening. Improved education and cervical cancer screening for WHIV are sorely needed; self-collection based screening has the potential to be integrated with routine HIV care in this setting.

Strategies for Community Education Prior to Clinical Trial Recruitment for a Cervical Cancer Screening Intervention in Uganda.

INTRODUCTION: Community engagement and education can improve acceptability and participation in clinical trials conducted in Kisenyi, Uganda. In preparation for a randomized controlled trial exploring different methods for cervical cancer screening, we explored optimal engagement strategies from the perspective of community members and health professionals. METHODS: We conducted key informant interviews followed by serial community forums with purposeful sampling and compared the perspectives of women in Kisenyi (N = 26) to health-care workers (HCW) at the local and tertiary care center levels (N = 61) in a participatory, iterative process. RESULTS: Key themes identified included format, content, language, message delivery, and target population. Women in Kisenyi see demonstration as a key part of an educational intervention and not solely a didactic session, whereas health professionals emphasized the biomedical content and natural history of cervical cancer. Using local language and lay leaders with locally accessible terminology was more of a priority for women in Kisenyi than clinicians. Simple language with a clear message was essential for both groups. Localization of language and reciprocal communication using demonstration between community members and HCW was a key theme. CONCLUSION: Although perceptions of the format are similar between women and HCW, the content, language, and messaging that should be incorporated in a health education strategy differ markedly. The call for lay leaders to participate in health promotion is a clear step toward transforming this cervical cancer screening project to be a fully participatory process. This is important in scaling up cervical cancer screening programs in Kisenyi and will be central in developing health education interventions for this purpose.

Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial.

OBJECTIVES: To compare two cervical cancer screening methods: community-based self-collection of high-risk human papillomavirus (HR-HPV) testing and visual inspection with acetic acid (VIA). METHODS: Pilot randomised controlled trial of 500 women aged 30-65 in the community of Kisenyi, Uganda. Women randomised to self-collection-based HR-HPV testing provided a cervico-vaginal swab for HR-HPV, and results were provided by phone after laboratory testing. Women who tested HPV positive were referred for VIA at the local health unit. Women randomised to VIA underwent screening at the local health unit, where women who tested positive with VIA were provided cryotherapy at time of screening, as per local standard of care. Women were referred for colposcopy when indicated. Outcome measures were uptake of screening, HR-HPV prevalence, VIA result and treatment rates. RESULTS: In the HR-HPV arm, 248 of 250 (p < 0.01) women provided samples, while in the VIA arm, 121 of 250 (48.4%) women attended screening. Among the 73 of 248 HR-HPV-positive women, 45.2% (N = 33) attended VIA screening for follow-up, 21.2% (N = 7) of whom screened positive; five received treatment and two were missing clinical follow-up records. Of the 121 women in the VIA arm who attended screening, 13.2% (N = 16) screened positive; seven received cryotherapy, three refused treatment, five were referred to colposcopy; and one woman had suspected cervical cancer and received treatment after confirmatory testing. CONCLUSIONS: This pilot study demonstrated trial feasibility and willingness of the women to participate and be randomised successfully into the two arms. Self-collection-based cervical cancer screening had a higher uptake than VIA.

The worldwide epidemic of female obesity.

The rapidly rising number of individuals who are overweight and obese has been called a worldwide epidemic of obesity with >35% of adults today considered to be overweight or obese. Women are more likely to be overweight and obese than their male counterparts, which has far-reaching effects on reproductive health and specifically pregnancy, with obese women facing an increased risk of gestational diabetes, preeclampsia, operative delivery, fetal macrosomia, and neonatal morbidity. The etiology of obesity is highly complex encompassing genetic, environmental, physiologic, cultural, political, and socioeconomic factors, making it challenging to develop effective interventions on both a local and global scale. This article describes the extent and the cost of the obesity epidemic, which, although historically seen as a disease of high-income countries, is now clearly a global epidemic that impacts low- and middle-income countries and indigenous groups who bear an ever-increasing burden of this disease.

Understanding the role of embarrassment in gynaecological screening: a qualitative study from the ASPIRE cervical cancer screening project in Uganda.

OBJECTIVE: To define embarrassment and develop an understanding of the role of embarrassment in relation to cervical cancer screening and self-collected human papillomavirus (HPV) DNA testing in Uganda. DESIGN: Cross-sectional, qualitative study using semistructured one-to-one interviews and focus groups. PARTICIPANTS: 6 key-informant health workers and 16 local women, purposively sampled. Key informant inclusion criteria: Ugandan members of the project team. Focus group inclusion criteria: woman age 30-69 years, Luganda or Swahili speaking, living or working in the target Ugandan community. EXCLUSION CRITERIA: unwillingness to sign informed consent. SETTING: Primary and tertiary low-resource setting in Kampala, Uganda. RESULTS: In Luganda, embarrassment relating to cervical cancer is described in two forms. 'Community embarrassment' describes discomfort based on how a person may be perceived by others. 'Personal embarrassment' relates to shyness or discomfort with her own genitalia. Community embarrassment was described in themes relating to place of study recruitment, amount of privacy in dwellings, personal relationship with health workers, handling of the vaginal swab and misunderstanding of HPV self-collection as HIV testing. Themes of personal embarrassment related to lack of knowledge, age and novelty of the self-collection swab. Overall, embarrassment was a barrier to screening at the outset and diminished over time through education and knowledge. Fatalism regarding cervical cancer diagnosis, worry about results and stigma associated with a cervical cancer diagnosis were other psychosocial barriers described. Overcoming psychosocial barriers to screening can include peer-to-peer education, drama and media campaigns. CONCLUSIONS: Embarrassment and other psychosocial barriers may play a large role at the onset of a screening programme, but over time as education and knowledge increase, and the social norms around screening evolve, its role diminishes. The role of peer-to-peer education and community authorities on healthcare cannot be overlooked and can have a major impact in overcoming psychosocial and social barriers to screening.

Factors associated with high-risk HPV positivity in a low-resource setting in sub-Saharan Africa.

OBJECTIVE: We sought to determine demographic and behavioral factors associated with human papillomavirus (HPV) positivity in a community-based HPV self-collection cervical cancer screening pilot project. STUDY DESIGN: HPV self-collected samples were obtained from 199 women aged 30-69 years in the impoverished urban Ugandan community of Kisenyi, during September through November 2011. Demographic and behavioral information was collected. Descriptive statistics and a logistic regression model were used to analyze factors associated with HPV positivity. RESULTS: There was overwhelming acceptance of HPV self-collection in this community. High-risk HPV prevalence was found to be 17.6%. Lower levels of formal education (adjusted odds ratio [AOR], 0.40; 95% confidence interval [CI], 0.08-2.03) were associated with higher prevalence of HPV as was use of oral contraception (AOR, 2.01; 95% CI, 0.83-4.90) and human immunodeficiency virus status (AOR, 0.43; 95% CI, 0.14-1.37). CONCLUSION: Screening should be targeted and prioritized for women with lower levels of education, oral contraceptive use, and human immunodeficiency virus positivity as they have the highest HPV prevalence in this low-resource population.

Results of a community-based cervical cancer screening pilot project using human papillomavirus self-sampling in Kampala, Uganda.

OBJECTIVE: To examine the feasibility of a community-based screening program using human papillomavirus (HPV) self-sampling in a low-income country with a high burden of cervical cancer. METHODS: A pilot study was conducted among 205 women aged 30-69years in the Kisenyi district of Kampala, Uganda, from September 5 to October 30, 2011. Women were invited to provide a self-collected specimen for high-risk oncogenic HPV testing by outreach workers at their homes and places of gathering in their community. Specimens were tested for HPV, Neisseria gonorrhoeae and Chlamydia trachomatis. Women who tested positive for HPV were referred for colposcopy, biopsy, and treatment at a regional hospital. RESULTS: Of the 199 women who provided a specimen, 35 (17.6%) tested positive for HPV. The outreach workers were able to provide results to 30 women (85.7%). In all, 26 (74.3%) of the women infected with HPV attended their colposcopy appointments and 4 (11.4%) women were diagnosed with grade 3 cervical intraepithelial neoplasia. CONCLUSION: Self-collection of samples for community-based HPV testing was an acceptable option; most women who tested positive attended for definitive treatment. Self-sampling could potentially allow for effective recruitment to screening programs in limited-resource settings.

Assessing women's willingness to collect their own cervical samples for HPV testing as part of the ASPIRE cervical cancer screening project in Uganda.

OBJECTIVE: To assess women's willingness to collect their own samples for HPV testing as the first part of a screening program for cervical cancer in Uganda. METHODS: In March and April 2010, trained assistants from Kisenyi interviewed 300 women aged 30 to 65 years who lived and/or worked in this community. Descriptive data and multivariate modeling were used to identify the predictors of the women's willingness to collect their own cervical samples. RESULTS: More than 80% of the 300 participants were willing to collect their own samples. In multivariate modeling, factors positively associated with this willingness were agreement to let outreach workers deliver the necessary swab at their homes (adjusted odds ratio [AOR], 4.10; 95% confidence interval [CI], 1.83-9.18) and willingness to undergo a pelvic examination if the sample was abnormal (AOR, 3.91; 95% CI,1.03-14.90). Factors negatively associated were embarrassment at collecting the sample at home where they lacked privacy (AOR, 0.09; 95% CI, 0.03-0.29) and concern of not collecting the sample properly (AOR, 0.1; 95% CI, 0.05-0.3). CONCLUSION: Self-collection is an option in impoverished settings in Africa. To improve acceptability, women should be taught how to properly collect their own cervical sample and encouraged to find ways to make the collection less embarrassing.

Attenuation of cytoadherence of Plasmodium falciparum to microvascular endothelium under flow by hemodilution.

The cytoadherence of Plasmodium falciparum-infected erythrocytes (IRBCs) to endothelium is mediated by adhesion molecules within the physical constraints of a viscous fluid containing mostly erythrocytes. The volume fraction of erythrocytes (hematocrit) and their physical properties, such as deformability, are important properties of blood that affect cell recruitment to the vascular wall. In the present study, we examined the effect of hematocrit on IRBC rolling and adhesion on human microvascular endothelial cells in a flow chamber system in vitro. We found hematocrit to be a major determinant of IRBC/endothelial cell interactions. There was a 5-fold and 12-fold increase in IRBC rolling and adhesion, respectively, when hematocrit increased from 10% to 30%, as a result of changes in shear rate. Similar effects were seen in the presence of less deformable erythrocytes, serum proteins, and on endothelium stimulated with tumor necrosis factor-alpha. The results indicate that hemorheologic variations are an important determinant of the degree of cytoadherence.